Practical guide to the use of digital slides in histopathology education.

Digital pathology (the technology whereby glass histology slides are scanned at high resolution, digitised, stored and shared with pathologists, who can view them using microscopy software on a screen) is transforming the delivery of clinical diagnostic pathology services around the world. In addition to adding value to clinical histopathology practice, digital histology slides provide a versatile medium to achieve the educational needs of a variety of learners including undergraduate students, postgraduate doctors in training and those pursuing continuing professional development portfolios. In this guide, we will review the principal use cases for digital slides in training and education and I will share tips for successful use of digital pathology to support a range of learners based on experience gathered at Leeds Teaching Hospitals National Health Service Trust and the National Pathology Imaging Co-Operative during the last 5 years of digital slide usage.

Histopathologic evaluation of gastric intestinal metaplasia in non-neoplastic biopsy specimens: Accuracy and interobserver reliability among general pathologists and pathology residents.

OBJECTIVES: This study aimed to evaluate the accuracy and interobserver reliability of diagnosing and subtyping gastric intestinal metaplasia (IM) among general pathologists and pathology residents at a university hospital in Thailand, focusing on the challenges in the histopathologic evaluation of gastric IM for less experienced practitioners. METHODS: The study analyzed 44 non-neoplastic gastric biopsies, using a consensus diagnosis of gastrointestinal pathologists as the reference standard. Participants included 6 general pathologists and 9 pathology residents who assessed gastric IM and categorized its subtype (complete, incomplete, or mixed) on digital slides. After initial evaluations and receiving feedback, participants reviewed specific images of gastric IM, as agreed by experts. Following a one-month washout period, a reevaluation of the slides was conducted. RESULTS: Diagnostic accuracy, interobserver reliability, and time taken for diagnosis improved following training, with general pathologists showing higher accuracies than residents (median accuracy of gastric IM detection: 100 % vs. 97.7 %). Increased years of experience were associated with more IM detection accuracy (p-value<0.05). However, the overall median accuracy for diagnosing incomplete IM remained lower than for complete IM (86.4 % vs. 97.7 %). After training, diagnostic errors occurred in 6 out of 44 specimens (13.6 %), reported by over 40 % of participants. Errors involved omitting 5 slides with incomplete IM and 1 with complete IM, all showing a subtle presence of IM. CONCLUSIONS: The study highlights the diagnostic challenges in identifying incomplete gastric IM, showing notable discrepancies in accuracy and interobserver agreement. It underscores the need for better diagnostic protocols and training to enhance detection and management outcomes.

An Innovative Workshop Embedding Pathology Service Users into the Undergraduate Biomedical Science Curriculum.

The integration of pathology service users into the biomedical science curriculum has been driven by the refinement of the Health and Care Professions Council (HCPC) Standards of Proficiency. This study aimed to design and implement a novel and innovative service user event with a reflective assessment to enhance students' knowledge and understanding of the impact of pathology laboratory results on the patient pathway. The 4-h workshop consisted of a series of service users. Patients discussed how pathology services had contributed to their diagnosis and treatment, while service providers-a Microbiology Consultant, a director of primary care, and the patient referral optimisation officer-discussed their roles and their interactions with pathology services. Post-event, students completed a 750-word reflective assessment, highlighting challenges experienced by service users and providing suggestions for improving the delivery of pathology services. In total, 57.5% of respondents (57/99) completed a post-reflection survey, which included open- and closed-ended questions. Quantitative analysis of the survey data revealed that over 87.7% of respondents had increased knowledge and understanding of the revised HCPC standards. Following the assessment, students reported a significant increase in their confidence with respect to reflective writing (p < 0.001), with over 90% of respondents agreeing that the reflective assessment had increased their knowledge and understanding of the limitations that may negatively impact service users and patient care. Moreover, respondents highlighted how advancements in point-of-care testing (POCT) and improvements in communication can improve patient experiences. Thematic analysis revealed that respondents agreed that embedding patients into the curriculum reinforced the importance of there being a patient behind every sample. Respondents reported that reflecting upon service user experiences enabled them to identify improvements to the delivery of pathology services while recognising the essential role that Biomedical Scientists play in the patient pathway. This successful workshop has created a platform encompassing a range of pathology service users in the undergraduate curriculum. We recommend that other accredited biomedical science programmes adopt and embed this innovative workshop and reflective assessment into their programmes to help them meet these standards relating to service users while fostering important transferable skills in their students.

Analyzing Anatomic Pathology On-Call Summaries to Improve Resident Education.

CONTEXT.­: Pathology on-call experiences help prepare trainees for successful transition from residency to independent practice, and as such are an integral component of training. However, few data exist on anatomic pathology resident on-call workload and experience. OBJECTIVE.­: To obtain an overall picture of the anatomic pathology on-call experience to inform and improve resident education. DESIGN.­: Retrospective and prospective review of daily anatomic pathology on-call summaries from July 2016 to June 2020. RESULTS.­: During the first 2 years of the study (ie, retrospective portion), only 19% of on-call summaries (138 of 730) were available for review. After interventions, the on-call summary submission rate jumped to 98% (716 of 731). After-hours calls were most frequent on weekdays from 5 to 8 pm. The most frequent requests were for frozen sections (55%; 619 of 1125 calls), inquiries regarding disposition of fresh placentas (13%; 148 of 1125 calls), and inquiries regarding disposition of various other specimens (6%; 68 of 1125 calls). After-hours frozen section requests were most frequent for gynecologic and head and neck specimens. Notably, a significant number of after-hours calls were recurring preanalytic issues amenable to system-level improvements. We were able to eliminate the most common of these recurring preanalytic calls with stepwise interventions. CONCLUSIONS.­: To our knowledge, this is the first study analyzing the anatomic pathology resident on-call experience. In addition to obtaining a broad overview of the residents' clinical exposure on this service, we identified and resolved issues critical to optimal patient care (eg, inconsistent "patient hand-off") and improved the resident on-call experience (eg, fewer preanalytic calls increased resident time for other clinical, educational, or wellness activities).

The utility of digital pathology in improving the diagnostic skills of pathology trainees in commonly encountered pigmented cutaneous lesions during the COVID-19 pandemic: A single academic institution experience.

Digital pathology has become an integral part of pathology education in recent years, particularly during the COVID-19 pandemic, for its potential utility as a teaching tool that augments the traditional 1-to-1 sign-out experience. Herein, we evaluate the utility of whole slide imaging (WSI) in reducing diagnostic errors in pigmented cutaneous lesions by pathology fellows without subspecialty training in dermatopathology. Ten cases of 4 pigmented cutaneous lesions commonly encountered by general pathologists were selected. Corresponding whole slide images were distributed to our fellows, along with two sets of online surveys, each composed of 10 multiple-choice questions with 4 answers. Identical cases were used for both surveys to minimize variability in trainees' scores depending on the perceived level of difficulty, with the second set being distributed after random shuffling. Brief image-based teaching slides as self-assessment tool were provided to trainees between each survey. Pre- and post-self-assessment scores were analyzed. 61% (17/28) and 39% (11/28) of fellows completed the first and second surveys, respectively. The mean score in the first survey was 5.2/10. The mean score in the second survey following self-assessment increased to 7.2/10. 64% (7/11) of trainees showed an improvement in their scores, with 1 trainee improving his/her score by 8 points. No fellow scored less post-self-assessment than on the initial assessment. The difference in individual scores between two surveys was statistically significant (p = 0.003). Our study demonstrates the utility of WSI-based self-assessment learning as a source of improving diagnostic skills of pathology trainees in a short period of time.

Medical Education in Pathology: General Concepts and Strategies for Implementation.

CONTEXT.­: Pathology education must evolve as medical knowledge expands and disruptive technologies emerge. The evolution in pathology teaching practices accelerated as traditional teaching modalities were suspended in March 2020 during the coronavirus disease 2019 (COVID-19) pandemic. OBJECTIVES.­: To provide pathologists an overview of established teaching paradigms and practical examples of how these paradigms may be applied to pathology education, emphasizing differences in graduate and undergraduate medical education as well as the challenges and promises of remote learning, as revealed by the COVID-19 pandemic. DATA SOURCES.­: Selected peer-reviewed publications representing the field of educational social science. CONCLUSIONS.­: Evidence-based methods described in education and social sciences can be effectively deployed in pathology education and especially remote learning, as necessitated by the current COVID-19 pandemic. Understanding established principles, such as cognitive load, competency-based learning, peer-assisted learning, and flipped classrooms may prove useful in developing effective, learner-centric content for pathology education.

Best practices of handling, processing, and interpretation of small intestinal biopsies for the diagnosis and management of celiac disease: A joint consensus of Indian association of pathologists and microbiologists and Indian society of gastroenterology.

The Indian Association of Pathologists and Microbiologists (IAPM) and Indian Society of Gastroenterology (ISG) decided to make a joint consensus recommendation for handling, processing, and interpretation of SI biopsies for the diagnosis and management of celiac disease (CD) recognizing the inhomogeneous practice of biopsy sampling, orientation, processing, and interpretation. A modified Delphi process was used to develop this consensus document containing a total of 42 statements and recommendations, which were generated by sharing the document draft, incorporating expert's opinion, followed by three cycles of electronic voting as well as a full-day face-to-face virtual ZOOM meeting and review of supporting literature. Of the 42 statements, 7 statements are on small intestinal (SI) biopsy in suspected patients of CD, site and the number of biopsies; 7 on handling, fixative, orientation, processing, and sectioning in pathology laboratories; 2 on histological orientation; 13 statements on histological interpretation and histological grading; 3 on the assessment of follow-up biopsies; 2 statements on gluten-free diet (GFD)-nonresponsive CD; 4 on challenges in the diagnosis of CD; 2 statements each on pathology reporting protocol and training and infrastructure in this area. The goal of this guideline document is to formulate a uniform protocol agreed upon both by the experienced pathologists and gastroenterologists to standardize the practice, improve the yield of small bowel biopsy interpretation, patients' compliance, overall management in CD, and generate unified data for patient care and research in the related field.

Pathology Residency Curriculum: Time for a Change?

The current Anatomical and Clinical Pathology residency curriculum, as outlined by the American Board of Pathology (ABP), emphasizes resident exposure to a wide variety of subjects without in-depth training. This has led to a large number of residents pursuing fellowship training. With the demand for further sub-specialization, there is a necessity for the establishment of an updated curriculum that not only encompasses the basic knowledge of pathology but is also focused on training residents in their desired subspecialty.We herein propose a new comprehensive AP/CP residency syllabus. The new curriculum will be divided into two major categories: preliminary and subspecialty training. The curriculum will require residents to undergo basic pathology training within the first two preliminary years, followed by two subspecialty years. In their subspecialty years, each resident will be required to either pick two subjects as majors, each having a duration of one year, or one subject as a major and two subjects as minors, in which case the major will have a one-year duration and the minors will each be six months in length. The proposed curriculum meets the current guidelines of the ABP, reduces the burden of residents to complete multiple fellowships, and allows residents earlier entrance into the workforce.

Pathology Informatics Education during the COVID-19 Pandemic at Memorial Sloan Kettering Cancer Center (MSKCC).

This review details the development and structure of a four-week rotation in pathology informatics for a resident trainee at Memorial Sloan Kettering Cancer Center (MSKCC) in New York City so that other programs interested in such a rotation can refer to. The role of pathology informatics is exponentially increasing in research and clinical practice. With an ever-expanding role, training in pathology informatics is paramount as pathology training programs and training accreditation bodies recognize the need for pathology informatics in training future pathologists. However, due to its novelty, many training programs are unfamiliar with implementing pathology informatics training. The rotation incorporates educational resources for pathology informatics, guidance in the development, and general topics relevant to pathology informatics training. Informatics topics include anatomic pathology related aspects such as whole slide imaging, laboratory information systems, image analysis, and molecular pathology associated issues such as the bioinformatics pipeline and data processing. Additionally, we highlight how the rotation pivoted to meet the department's informatics needs while still providing an educational experience during the onset of the COVID-19 pandemic. CONCLUSION: As pathology informatics continues to grow and integrate itself into practice, informatics education must also grow to meet the future needs of pathology. As informatics programs develop across institutions, such as the one detailed in this paper, these programs will better equip future pathologists with informatics to approach disease and pathology.

Digital Pathology Initiatives and Experience of a Large Academic Institution During the Coronavirus Disease 2019 (COVID-19) Pandemic.

CONTEXT.­: Pathology practices have begun integrating digital pathology tools into their routine workflow. During 2020, the coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), emerged as a pandemic, causing a global health crisis that significantly affected the world population in several areas, including medical practice, and pathology was no exception. OBJECTIVE.­: To summarize our experience in implementing digital pathology for remote primary diagnosis, education, and research during this pandemic. DESIGN.­: We surveyed our pathologists (all subspecialized) and trainees to gather information about their use of digital pathology tools before and during the pandemic. Quality assurance and slide distribution data were also examined. RESULTS.­: During the pandemic, the widespread use of digital tools in our institution allowed a smooth transition of most clinical and academic activities into remote with no major disruptions. The number of pathologists using whole slide imaging (WSI) for primary diagnosis increased from 20 (62.5%) to 29 (90.6%) of a total of 32 pathologists, excluding renal pathology and hematopathology, during the pandemic. Furthermore, the number of pathologists exclusively using whole slide imaging for primary diagnosis also increased from 2 (6.3%) to 5 (15.6%) during the pandemic. In 35 (100%) survey responses from attending pathologists, 21 (60%) reported using whole slide imaging for remote primary diagnosis following the Centers for Medicare and Medicaid Services waiver. Of these 21 pathologists, 18 (86%) responded that if allowed, they will continue using whole slide imaging for remote primary diagnosis after the pandemic. CONCLUSIONS.­: The pandemic served as a catalyst to pathologists adopting a digital workflow into their daily practice and realizing the logistic and technical advantages of such tools.

[Assessment of aptitude for anatomic-clinic correlation in pediatric pathology]. / Evaluación de la aptitud para la correlación anatomo-clínica en patología pediátrica.

Introduction: In the 18th Century, Giovanni Battista Morgagni demonstrated that localized injuries to different organs caused a great variety of clinical symptoms and signs. Since then, medical practice has evolved considerably and maintains the correlation of pathological changes with the signs and symptoms of the disease as part of the academic activity known as "anatomic-clinical session". The evaluation of the aptitude for the anatomic-clinical correlation has not been empirically estimated in pediatric pathology. Objective: Construct and validate an evaluation instrument to quantitatively estimate the aptitude for the anatomical-clinical correlation in pediatric pathology (AA-CCPP). Method: Analytical cross-sectional study. An evaluation instrument was constructed with 90 true, false and I don't know type statements, grouped based on three indicators: I, diagnostic integration; II, identification of pathogenic mechanisms and III, identification of clinical and paraclinical data. The instrument was applied to three groups of residents. The Kruskal-Wallis test was used to compare the results between the groups. Results: The AA-CCPP grade was very low in most residents. When comparing the global scores between the different groups, the pediatric pathology group was the highest. The indicator that obtained the best results was that of Diagnostic Integration. Conclusions: The level of development of the AA-CCPP observed allows us to deduce that the learning strategy known as clinical-pathological conference should be strengthened.

Introducción: En el siglo xviii, Giovanni Battista Morgagni demostró que las lesiones localizadas en diferentes órganos condicionaban gran variedad de síntomas y signos clínicos. Desde entonces, la práctica médica evolucionó considerablemente y conserva la correlación de los cambios anatomopatológicos con los signos y síntomas de la enfermedad como parte de la actividad académica conocida como «sesión anatomoclínica¼. La evaluación de la aptitud para la correlación anatomo-clínica no ha sido estimada empíricamente en patología pediátrica. Objetivo: Construir y validar un instrumento de evaluación para estimar de manera cuatitativa la aptitud para la correlación anatomo-clínica en patología pediátrica (ACA-CPP). Método: Estudio tranversal analítico. Se construyó un instrumento de evaluación con 90 enunciados tipo verdadero, falso y no sé, agrupados en tres indicadores: I) integración diagnóstica; II) identificación de mecanismos patogénicos; y III) identificación de datos clínicos y paraclínicos. Se aplicó el instrumento a tres grupos de residentes. Para comparar los resultados entre los grupos se utilizó la prueba de Kruskal-Wallis. Resultados: El grado de ACA-CPP fue muy bajo en la mayoría de los residentes. Al comparar las puntuaciones globables entre los diferentes grupos, el de patología pediátrica fue el más alto. El indicador que obtuvo mejores resultados fue el de integración diagnóstica. Conclusiones: El nivel de desarrollo de la ACA-CPP observado permite deducir que la estrategia de aprendizaje conocida como sesión anatomo-clínica debe fortalecerse.

The acceptance and impact of Google Classroom integrating into a clinical pathology course for nursing students: A technology acceptance model approach.

BACKGROUND: Google Classroom (GC) is a free web-based instructional platform rarely used for nursing student education. The acceptance, intention to use, and learning outcomes of GC remain unclear in Taiwan. We sought to identify the technology acceptance level and factors affection the intention to use GC. We also explored how integrating GC into traditional teaching affects learning satisfaction and academic achievement among nursing students in Taiwan. METHODS: In this randomized controlled study, based on a technology acceptance framework, 74 nursing students were randomly assigned in clusters to experimental (n = 39) and control (n = 35) groups during the spring semester of 2018. In Weeks 3-18, each member of the experimental group received one hour of traditional and GC teaching per week. The control group received two hours of traditional teaching per week. Both groups were asked to complete questionnaires to evaluate learning satisfaction and academic achievement during weeks 10 (mid-semester) and 18 (end-of-semester). The experimental group additionally completed technology acceptance questionnaires in both situations. FINDINGS: In the experimental group, the overall end-of-semester technology acceptance score was high (141.8 out of 155); their perceived ease of use, intention to use, and technology acceptance scores increased significantly compared to mid-semester (p<0.05). At the end-of-semester, perceived playfulness and perceived usefulness explained 63.5% of the variance in intention to use. Regardless of whether the assessment was administered mid-semester or at the end-of-semester, the experimental group had higher learning satisfaction and academic achievement scores than the control group. However, the degree of progress on learning satisfaction and academic achievement demonstrated no significant between-group differences. CONCLUSIONS: The experimental group demonstrated high acceptance of GC. Playfulness and usefulness positively influenced nursing students' intention to use GC. Blended learning-in combination with GC and traditional methods-resulted in similar learning satisfaction and academic achievement when compared to traditional learning. More research is needed to explore the effectiveness of blended learning through the GC platform with different courses and ethnic groups.

Highlights and Perspectives From a Collaborative Global Health Pathology Experience in Trinidad and Tobago.

OBJECTIVES: Global health education is important during residency training in exposing doctors to conditions that are not common in the United States and developing their awareness of global health care disparities. Most medical decisions are based on results from anatomic or clinical pathology laboratories, which are essential services for appropriate medical care in international settings. Nevertheless, US pathology residency trainees have limited global health exposure and thus are rarely exposed to diagnostic services in these settings. Moreover, literature documenting what is needed to create a global health elective in pathology is limited. METHODS: We designed an international pathology elective in Trinidad and Tobago involving one main public hospital site and several off-site laboratories. Objectives and goals were established before the rotation. Apart from daily mentor-led education sessions, the trainee participated in teaching, quality improvement projects, and cultural experiences. Engagement with medical officers, personnel staff, and people in the community was encouraged.Results: Challenges encountered included funding, transportation, limited laboratory resources, medical registration, and malpractice insurance. These were mitigated through carefully planned steps, including communicating with registration bodies and liaising with pathology organizations for funding. CONCLUSIONS: Overall, the global health rotation was successful. We provide a detailed roadmap for other pathology training programs interested in establishing similar global health electives.

A short course in visual literacy can improve residents' observation and descriptive skills in cytopathology.

Visual literacy is an essential skill in Anatomical Pathology. However, there appears to be a dearth of literature that engages explicitly with how to teach or learn visual skills with respect to Anatomical Pathology residents. Using a variety of modalities, with a focus on practical arts-based methodologies, three-two hour workshops were designed to explore the complexity of precise observation and structured description. This intervention was based on the hypothesis that cytopathology and analyzing an artwork share a language and set of formal processes. Evaluation of the workshops was both quantitative and qualitative. The former assessed pre- and post-workshop descriptions of cytology images and artworks while the latter was in the form of a focus group. An actual improvement in both cytopathology and artwork description was demonstrated while the focus group discussion revealed the majority of residents considered the workshops as having a positive impact on the observation and description skills required in Anatomical Pathology. Some felt the purpose and approach of these workshops was not made explicit enough. Thematic analysis of the focus group showed robust discussion regarding who should conduct these workshops and when they should be conducted in resident training. Unanticipated benefits of the workshops such as personal creativity and pleasure formed a significant theme that requires serious consideration. Introducing visual literacy workshops into residency training appears to be valuable and improved observation and description skills in cytopathology. The focus group discussion will be used to improve on this first set of workshops.

[Histopathologic grading of breast cancer; large variation with major consequences?] / Histopathologische gradering van het mammacarcinoom.

The pathologist's assessment of tumor tissue plays a critical role in therapeutic decision-making in early-stage invasive breast cancer. In daily practice, however, there appears to be considerable variation in grading between the different Dutch pathology laboratories and between individual pathologists within the same laboratory. This underlines the need to standardize grading by pathologists as much as possible in order to minimize the risk of a worse outcome for patients due to under-treatment and of unnecessary toxicity from over-treatment. Therefore, two initiatives were launched, i.e. laboratory-specific feedback reports and an e-learning module in which pathologists were trained in grading of invasive breast cancer. While these initiatives have yielded encouraging results, the overall variation in grading remains significant. Awareness of this variation, and of the inherent difficulties of subjective grading, among the various clinicians involved in breast cancer management, is therefore of utmost importance to improve clinical decision-making for patients.

El nuevo rumbo de la docencia de residentes: ¿hacia dónde y por qué? / The new direction of teaching residents: Where and why?

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Autopsy Education in Canadian Pathology Programs: A Survey of Canadian Trainees.

INTRODUCTION: This survey of Canadian pathology residents was designed to quantify the number of autopsies Canadian residents aim to complete during residency training, to better understand the perception of residents about access and quality of autopsy skills education. In addition, the interest of current pathology residents in autopsy and forensic pathology as a future career was also assessed. METHODS: A web-based survey was sent to all Canadian pathology residents. This survey consisted of 19 questions on institution, level of training, intention to complete the American Board of Pathology examination, number of autopsies completed, perception of quality/access to autopsy skills education, interest, and factors contributing to autopsy and forensic pathology. RESULTS: Eighty two (26%) of a possible 310 residents (12/47 general pathology, 70/263 anatomical pathology) across all Canadian institutions offering anatomical or general pathology programs (16/16 institutions) participated in the survey. Eighty-three percent of the respondents rated autopsy education as either very important or important. Fifty-five percent of the respondents intended to either challenge the American Board of Pathology examination or wanted the option to do so in the future, whereas only 47% of the participants agreed that all residents who wish to challenge the examination will easily be able to complete 50 autopsies during residency. Only 18% of the respondents were interested in performing autopsies as a major part of their career, and a combined 52% were only interested in performing autopsies to secure a desired position or felt that having to do autopsies would be a job deterrent. The quality of autopsy teaching received and the number of autopsies performed was identified as the most significant factors affecting interest in performing autopsies as part of a future career. A combined 68% of the respondents felt that the job market in forensic pathology in Canada was either good (better than most subspecialties) or very good (more jobs than graduating fellows). Seventy-one percent (12/17) of postgraduate year 5 respondents reported having completed 50 or more autopsies at the time of survey completion. Eleven percent of the respondents did not agree that all residents who document having completed an autopsy at their institution will have participated in all 8 essential autopsy tasks. Twenty four (29%) of the 82 respondents provided detailed narrative comments. DISCUSSION: Most Canadian pathology residents believe that autopsy education is an important component of residency training. Limited access to quality autopsy teaching seems to be an important factor in resident interest in forensic pathology as a future career, despite a perceived good job market in comparison with most other subspecialties.